Tuesday, December 25, 2007

i am very excited to announce that grand rounds is coming to the sunny shores of south africa next week. the first day of the new year will be celebrated here on my blog with a collection of the best medical blogs of the blogosphere.

although a loose theme of new beginnings will possibly be followed, any and all submissions are welcome as they should be, so get submitting, fellow medbloggers!

send submissions to bongi at amanzi dot com. please put the words "grand rounds" in the subject line. please place a link in the message. you are welcome to give a summary of the post, but this is not required.

the deadline for submissions is sunday 30 december. late submissions may not be included.

Friday, December 21, 2007

hijacking is common in south africa. so common that the government has placed signs to let you know where you are likely to get hijacked. there are some people that feel more should be done, especially if one bears in mind that you have a good chance of being shot during a hijacking.

in my post practice, there was a comment which hinted at our south african view of violence, due to the fact that it is so commonplace. yes we are desensitized. but doctors are also desensitized. so what happens when you bring all three of these elements together?

it was in my registrar days. i had recently written intermediates and had less academic stress to deal with. therefore on calls, if it was quiet enough, instead of going to the call room and studying, i found myself wandering around, looking for something to do. one of my favourite places was the casualty unit. and in the casualty unit, my favourite place was the resus room. this is where all the high drama took place. this is where the adrenaline flowed (often even into the patient). this is where i felt alive and at my most alert.

so that night i wandered down to casualties to see if anything was happening. in the resus room, sure enough, there was a guy lying on the table. a friend who was almost finished with thoracic surgery specialization was standing at his head. all seemed calm. then i saw someone else in the corner of the room, looking awkward and out of place. i looked at the patient. he had a nice round hole in his chest, just to the left of the heart. i put the story together in my mind.

the guy in the corner was the shooter. he was either a cop in plain clothes or some civilian that had intercepted some crime. because of a slight paranoia due to 'a beautiful mind' about people lurking in places they shouldn't be, i asked my friend who the guy was there in the corner. i was relieved to hear that he could also see him."he's an off duty cop who shot this f#@ker. i don't know who the f#@k teaches them to shoot? two f#@king centimeters more medial and i'd be in my warm f#@king bed now and he would be on a cold hard f#@king slate in the morgue. now i have to operate this f#@k!" that's just the way he spoke. he could be very descriptive with only one adjective. he had the unique knack of making swearing sound elegant.

i then got the story, more chronologically and with less profane interjections (also much less colourfully) from someone else. the patient (the one my friend referred to as the f#@k) was a hijacker. at a robot (south african for traffic light) he had smashed the side window of a car and pushed his 9mm up against the head of an old woman. in the car behind was the off duty policeman. he jumped out, raised his service piece and demanded that the hijacker desist (my friend wouldn't have used the word desist). the hijacker, maybe like my friend didn't understand the word, because he turned to shoot the cop. the cop's gun was drawn, cocked and aimed. there was little doubt about who was going to squeeze the first shot off. the round entered the patient square on in his chest just lateral of the heart on the left. it exited exactly posterior to this. i surmised that if he even had mild cardiomegaly, the shot would have been fatal. i think the criticism about the cop's aim was unwarranted.

armed with this new perspective i looked at the patient (f#@k). he looked back at me. he was stable, but the intercostal drain had a constant stream of blood running out. my friend stood back as a sister was placing a cvp. he was telling her what to do. she was learning. i looked into his eyes again. i could see the fear of death there. i wondered how many times he had seen that in other people's eyes and shown no mercy. but i was not him. i felt sorry for him.

my friend, meanwhile exchanged some words with the cop. i listened in. he was giving shooting advice. he was suggesting that the best place to aim is the center of the chest and not the left. i reflected that this is good advice. although the heart is ever so slightly to the left, it is actually in the center of the chest.

then i listened to the sister who seemed to be having a bit of trouble with the cvp. she had moved from the subclavian to the internal jugular. her head was now directly above that of the patient. she was muttering. i moved closer to hear what she was saying.she was speaking to the patient as she drove the needle repeatedly into the neck, searching for the vein.

she was saying things like:-"this thing would think nothing of killing me on the street and now i have to try to save it's life."and:-"here lies the reason the death penalty should be brought back."and similar things.

i mentioned to her something about not being a judge and having to care for whoever comes in without discrimination. she looked at me as if i wasn't a south african. i repeated what i had said, and then, knowing that my foul mouthed friend was good at what he does and the patient would be ok, if not somewhat emotionally scarred, i left.

i felt the need to tell this story to try to bring across the reality of how our job ends up messing us up. maybe being south african means we were messed up to begin with. i've often felt that we should go through some sort of debriefing. i doubt anyone can remain totally normal with all this sort of stuff constantly going on. it becomes a challenge to remain an exception. luckily i enjoy a challenge.

Saturday, December 15, 2007

ever wondered why what we do is called practice? one particular story brought it into stark reality.

i was doing my internship in qwa-qwa. the hospital where i worked was a secondary hospital servicing about one million people. but it suffered from the usual problems of no supplies and theft etc. the result was that certain items in casualties were kept under lock and key. these included drip sets, needles, jelcos and at the worst of it, even syringes. you can imagine the chaos in a resus situation.

the next consideration is the difference between a surgical resus and a medical resus. a surgical resus is usually easier. there is usually one problem. keep the patient alive long enough to find the problem, fix the problem and the patient recovers. the patient is leaking blood. find the leak, plug it, fill up the container and all is well.a medical resus is a completely different animal. once your body has crashed due to a medical problem, your reserves have been used up. there is usually not much that can be done. if you crash because your lungs have been eaten up by tb, no matter what you do, there is not enough working lung to keep the patient alive. when you crash because your liver doesn't have enough normal tissue to detox your blood, no matter what, there is not enough to keep you going. and so one can go on, organ by organ.

so, usually a medical resus is pretty much a waste of time. a surgical resus must be done efficiently and can mean the difference between life and death.

having set the stage, i was on call in casualties when a patient came in very late one night. he was wasted. there was thrush all over his mouth (often indicating terminal aids). he was very nearly not breathing and the occasinal gasping breaths he took sounded gurgling to the naked ear (no stethoscope needed). i knew tb had basically destroyed his lungs (working in qwa-qwa and hearing this breathing was almost synonymous with making this diagnosis). i could feel no pulse and hear no heart sounds (with a stethoscope). it was a pointless situation, like most medical resusses.

then a thought occured to me. bearing in mind the unit was not geared for resus due to the problems mentioned in the opening of this post and bearing in mind surgical resusses would be coming in in the future, it would be good to run through a resus where only i knew that it was pointless.

i jumped to action. i sent one sister to bring the ambubag endotracheal tubes and laryngoscope, another to unlock the closet with the needles and drips and yet another to get the drugs. soon i stood alone next to the patient. yes, that is how a resus went in that hospital all those years ago. you may better understand my desire to do a practice run in a situation where the outcome was already determined.

by the time everyone came back, the patient had stopped breathing. i moved to the head. as i was intubating, i orchestrated a full resus. one sister was put to work doing cardiac massage, two started getting iv access, one attached the ecg monitor and one started drawing up drugs. i tubed and started bagging. during the whole process i explained to the sisters what i was doing and why. i gave some pointers about how better they could perform their respective tasks. everything went well.

and then possibly the worst possible thing happened. the patient's heart started beating and his peripheral saturation began to climb. the sisters where ecstatic. i was worried. i had to find a place for him in the hospital now.

i phoned the physician (cuban). he said the patient couldn't go to icu because of the fact that there were no available beds. he asked me if the patient was breathing on his own. i stopped pumping his lungs and lo and behold, he was breathing. the physician made the call. he should be extubated and take his chances in the ward.

we extubated him and sent him to the ward. he was alive. the sisters in the ward were more than just a little annoyed with me for what they called going above and beyond the call of duty by resuscitating a corpse. they didn't call me when he crashed again. they made sure he was good and dead before they called me. even then i think they waited a few minutes to make sure there was no chance for him.

looking back on this, i realise there are a number of questions my international readers may raise. i even considered not posting it. but i think one must see these events in the context of the unique circumstances we worked under. when the surgical resus did come in, the entire casualty unit was more geared for it and it went better than it would have. those sisters there that night almost without exception thanked me for the entire thing. a rumour went around the hospital that i was the best intern to be on duty with. the only point that i didn't like was the negative attitude to me from the ward staff, but that was something i could easily get over.then there is the point of available resources. this is a reality in south africa. this blog is supposed to portray uniquely south african stories, so that part of the story also needs to be told.the point of the combination of hiv and tb, especially in those days when there was no available treatement here also shows a south african slant. that was the fact of the matter at that time and these deaths were commonplace. even these days, thanks to our minister's hiv policy, many people die unnecessarily all the time in similar condition.

Thursday, December 13, 2007

in our training, a friend and i tended to work together when it was the season. neither one of us really celebrated christmas (he was hindu and i didn't care for the commercialisms of the holiday), so it sort of worked out fine.

however, walking down to casualties to see yet another stab wound caused by festivities (read alcohol) and some trivial argument with his 'best friend' when pretty much everyone else was relaxing at home or some holiday destination could cause a bit of healthy scepticism in the so called meaning of the season.

we used to stroll down the deserted corridors, wiping the sleep out of our eyes on the way to casualties. one of us would say"'tis the season to be jolly!" and the other would reply,"fa-la-la-la-la-f#@king-la-la-la"

Thursday, December 06, 2007

i was asked to guest post on another south african medical blog. i have in fact already posted two of my older posts there. but now i have posted one unique post there. so, all people who visit here regularly, take a turn at all scrubbed up. have a look around. let me know if you like it.

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this blog was the runner up in the literary category of the 2009 and 2010 medical weblog awards

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disclaimer

the aim of this blog is to give insight into the mind of a particular surgeon, me. although every story is loosely based on fact, patients have been changed suitably to protect their identity. the opinions expressed are mine alone and are not meant to be considered medical advice or the opinion of any institution.